Rhinoplasty

Primary Rhinoplasty

Primary rhinoplasty, also known as “nose” or “nasal” surgery, corrects the nasal shape, size, and/or function for a patient who has never undergone nasal surgery. Before the primary rhinoplasty procedure, Dr. Constantian takes the time to ensure that he and his patients understand each other in terms of aesthetic goals. He personally meets with his patients and listens to their concerns and desires regarding the specific changes in appearance and function that they would prefer. Appearance is very personal, and each patient deserves the degree of change or preservation of ethnic or family identity that he or she wishes. Dr. Constantian then thoroughly assesses the patient for airway problems, the skin’s ability to shrink or take on a new shape, and areas of the nose that are anatomically too large or too small. Based on his discussion with the patient and his physical examination, Dr. Constantian explains what he can accomplish with surgery, and what he cannot, and creates a surgical plan that will achieve the patient’s cosmetic changes, maximize safety, and create the best airway.

Secondary Rhinoplasty

Secondary rhinoplasty, also known as revision rhinoplasty, corrects problems that resulted from a previous rhinoplasty procedure and constitutes 70% of Dr. Constantian’s practice. Dr. Constantian performs secondary rhinoplasty to help patients who have already undergone one or more nose surgeries and are now suffering from reduced airway function or serious cosmetic problems. The secondary rhinoplasty procedure is more difficult than primary rhinoplasty because the cartilage and bone that create the nasal shape have already been altered and may be scarred or deformed, the skin has become thicker and less pliable, and potential cartilage building materials have been used up. Dr. Constantian always considers safety, nasal balance, airway function, deformities of cartilage and bone, and areas that need additional support or reshaping to devise a safe plan that satisfies, to the greatest degree possible, the patient's aesthetic goals.

Our Approach

While many surgeons use the open approach to rhinoplasty, there are significant and rarely-discussed problems and limitations with this technique. We provide our patients with higher safety, quicker recovery, and more precise results that can be achieved with the closed rhinoplasty approach.

Open Rhinoplasty

Closed (Endonasal) Rhinoplasty

Incisions / Scars

Open Rhinoplasty

Visible, permanent scar across the tissue between the nostrils (columella)

Columella often becomes irreparably wider or deformed

Closed Rhinoplasty

Scars hidden within the nose

Columella remains narrow and unscarred

Dissection / Alterations

Open Rhinoplasty

Skin is lifted for access to underlying structures

Disrupts the interconnection of nasal parts so that shape and support have to be reestablished

Much more chance of creating new deformities

More disruptive to the circulation and, therefore, less safe in scarred or operated noses

Skin loss can occur

Closed Rhinoplasty

Alterations are made through the nostrils

Does not disrupt the normal support mechanisms

Only areas that will be changed are uncovered so that there is much less chance of creating new deformities

Little disruption of nasal circulation

Incisions are limited, so the closed approach is much safer in scarred or operated noses

The skin is much better protected

Surgeon’s Visibility

Open Rhinoplasty

Better view of internal structures, but the final surface shape is only the surgeon’s educated guess

The skin imparts half of the nasal shape and cannot be accurately assessed with open rhinoplasty

Closed Rhinoplasty

Better view of how changes to internal structures affect the nasal surface, details of shape, and nasal proportion

Much better capacity for the surgeon to make subtle changes and to assess the nuances of the surface and skin so that the patient’s goals are achieved

Framework Supports

Open Rhinoplasty

Artificial: internal struts often uphold the new nasal tip

Permanent internal sutures are often used, which can cause late infections

Closed Rhinoplasty

Natural: anatomical reconstruction of the new external shape and airway support

No internal structures are used to create shape

Recovery

Open Rhinoplasty

Longer surgery

More extensive

More swelling

Higher chance of new deformities or asymmetries

Closed Rhinoplasty

Shorter operating time

Less extensive

Less swelling

Much less chance of creating new deformities

Results

Open Rhinoplasty

Take longer to become visible

Closed Rhinoplasty

Airway improvement is immediate when dressings are removed

Surface shape appears more quickly

Why Choose Dr. Constantian

Mark B. Constantian, MD, FACS has been a board-certified plastic surgeon since 1979 and is an expert in the field of rhinoplasty. He is a past president of the New England Society of Plastic and Reconstructive Surgeons, the Northeastern Society of Plastic Surgeons and The Rhinoplasty Society and is also an active member of The American Society for Aesthetic Plastic Surgery and other prestigious plastic surgery societies. Dr. Constantian is Clinical Adjunct Professor of Surgery (Plastic Surgery) at the University of Wisconsin Medical Center and Visiting Professor of Plastic Surgery at the University of Virginia.

He has published many journal articles and textbook chapters on rhinoplasty and is the author of a recent two-volume textbook on rhinoplasty. Dr. Constantian teaches regularly at regional, national, and international plastic surgery meetings, and his outcome study on airway repair is the most cited article on nasal function since 1970. Dr. Constantian understands that rhinoplasty is as much an art as it is a science, and his years of extensive training and experience provide him with the skills needed to successfully execute difficult techniques with both accuracy and efficacy.

FAQs

Rhinoplasty is a complex surgery, so people naturally have many questions about the procedure. The following are some of the most common questions that patients ask Dr. Constantian during their initial consultations.

A. The septum almost always provides the best building material for the nose because it is generally flat and relatively straight, which is ideal for contouring the bridge or tip and supporting the airways. If there is not adequate septal cartilage to support and shape the nose, a graft of ear cartilage, rib cartilage or bone, or occasionally bone from the outer layer of the skull can be safely used. Synthetic materials, such as silicone, can slip out of place, have a higher risk of causing complications, and do not generally last for the patient’s entire lifetime. The patient’s own bone and cartilage will provide the most effective, long-lasting results.

A. Although the “deviated septum” is what most people think of when they think of a blocked nasal airway, the strength of the sidewalls is also very important. My published research in 600 patients since 1991 indicates that the valves in the sidewalls are more important for good nasal airflow than a straight septum. If the sides are too narrow or the cartilages are so soft that they collapse on inhalation, the airway will be poor even if the septum is straight. On most patients, I will straighten the septum and also support the sides because that gives a far superior result to simply straightening the septum. Some patients have already had a good septoplasty and I just need to stiffen the sides, in which case I can use septal cartilage if it is present or ear cartilage if it is not.

A. The need for revision rhinoplasty can have several causes: inadequate diagnosis, unexpected healing, or poor technique. The more experienced a surgeon is, the less commonly any of those situations occurs. After so many years of performing rhinoplasty, I almost always can make the diagnosis and a surgical plan that I have confidence will work. What I cannot control, however, is the quality of the graft materials or the patient’s healing. A surgeon can adjust for most variations in materials and often produce very good results even with suboptimal cartilage and bone. However, surgeons are not gods and neither control the quality of the cartilage nor the way in which the patient’s nose heals. It is those factors that create a variation in the beauty, smoothness, and function of the final result. If patients want the best result I can provide, additional surgery is occasionally necessary.

A. It is best to wait at least six months, and usually a year or more, before undergoing a revision surgery. Things that may not look good early on often improve over time, and occasionally a problem arises that was not apparent at first. Further, the tissues have to become soft enough for the revision rhinoplasty surgery to be safe and so that the skin will cooperate and permit me to make the types of changes that I would like. It is difficult to be patient when waiting for the nose to heal, but it is much worse to be rushed and fail to achieve what the patient wants because healing was not yet complete.

A. In a recent paper in Plastic and Reconstructive Surgery®, the official journal of the American Society of Plastic Surgeons, I showed research that indicated that about 20% of secondary rhinoplasty patients are unhappy because they have lost their sense of personal, ethnic, or familial identity, and another 70% have either uncorrected or new problems. This means that 90% of secondary rhinoplasty deformities are potentially avoidable by better patient/surgeon communication.

I have spent my career teaching surgeons how to achieve specific changes by understanding nasal structure. Many patients, especially those who fly here from Europe or the Middle East for surgery or have a strong ethnic identity, do not want obvious changes or want to retain certain nasal characteristics--tip or bridge shape, for example. This is all possible and is a routine part of my preoperative discussion with every patient.

Featured Procedure

Closed Rhinoplasty

Please contact us, if you are considering rhinoplasty or another plastic surgery procedure.